CAUTI PreventionBest Practices Update
San Diego/Imperial County APIC Chapter
April 13, 2016
Objectives
O Discuss chapter members experiences and
lessons-learned with RN-driven Foley
Removal Protocols
O Review other methods of CAUTI reduction
being implemented by chapter members
APIC identifies “no RN driven protocols
for Foley removal” = gap in CAUTI
reduction strategies
UCSD’s RN Driven Foley Removal Journey
O Implemented in May 2015
O Multi-disciplinary group to define “necessity” based on CDC guidelines and implement
O Education rolled out to all nursing groups through Clinical Nurse Specialists (CNS)
O Email sent to MD groups to educate
O Random audits by nursing to evaluate appropriate removal – revealed low use of RN Driven Foley removal order (<10%); 38% of patients had Foley in place without meeting any of our approved indications
UCSD Nurse Protocol for Removal of Foley/Post Removal Protocol
MD Order Set
Necessity
indications
2 of 3 choices
allow MDs to hang
on to Foley removal
California Confidential Evidence Code 1157
To date, overall UCSD ICU Foley utilization and CAUTI have remained steady
California Confidential Evidence Code 1157
Nice Work
California Confidential Evidence Code 1157
TICU – No CAUTI for 11 consecutive months
Other TICU Interventions
O 2014 – started Event Case Study
Investigations (CSI) – CAUTI drill down
O June 2015 RN-led inter-disciplinary daily
rounding on each patient – Foley/Central
necessity part of every patient rounding
O 2015 – Rock Star Program – recognition of
RNs with perfect Foley/Central Line bundles
Our challengesO Necessity guidelines vague/open to interpretation
O Example: Prolonged mobility – being interpreted as anyone who doesn’t care to get out of bed when indication is meant to reflect unstable spine or pelvis, maybe hemodynamic instability (post cath)
O Conflict of interpretation of necessity guidelines between physicians and nursingO Ann Arbor Study helpful
O http://annals.org/article.aspx?articleid=2280677
O Lack of use of RN driven Removal ProtocolO MD’s tell us they –
O Did not know we had one of these
O Do not trust RNs to NOT remove Foley prematurely (really?)
O We don’t have a good system of consistent weights for volume status monitoring – cardiac folks – fair point – need to fix
O Multiple choices beside RN driven (call first, critical Foley)
O Lack of consistent auditing/feedback process to determine gaps in education/intervention
Ann Arbor Appropriateness Studyhttp://annals.org/article.aspx?articleid=2280677
Meddings J, Saint S, Fowler KE, Gaies E, Hickner A, Krein SL, et al. The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients:
Results Obtained by Using the RAND/UCLA Appropriateness Method. Ann Intern Med
Your RN-driven Foley Removal Protocol successes/challenges?
Other CAUTI Reduction Interventions for Discussion
O Stop Orders
O Antimicrobial impregnated Foley catheters
O Insertion practice evaluation
O New products
O Change Foley before UTI-suspected urine specimen obtained/administration of antibiotics
O Routinely change Foley
O Bundle surveillance
O Peri-care initiatives
O Others?
CAUTI Scenario
O 35 year old male patient admitted to SICU
on 1/25/16 with spinal cord injury and Foley
catheter is placed. On 2/16 - 2/28/16 the
patient has recorded fever > 100.4. Foley is
removed on 2/25/16 and urine culture
collected on 2/27/16 positive for ≥ 100,000
P. aeruginosa.
O Is this a CAUTI?
Per NHSN, Yes – SUTI1aFoley in from 1/25-2/25
2/22 Foley in, + temp
2/23 Foley in, + temp
Infection
Window Period
2/24 Foley in, + temp (Date of Event)
2/25 Foley removed, + temp
2/26 + temp
Date of Culture 2/27 Date of Pos Culture
Infection
Window Period
2/28
2/29
3/1
The 2/24 fever is the first element to occur within the IWP and is the date
of event. The Foley was in place > 2 days on the date of event, therefore
this meets SUTI 1a: Catheter-associated Urinary Tract Infection (CAUTI).
Top Related